I (we) the undersigned, parent(s) guardian(s) of First Name* Last Name* , a minor, do hereby give consent and permission for the above named minor to participate in social skills, early intervention (TWISPP) or other group activities conducted through Therapy West, Inc. I (we) certify that the child is in good physical condition at the present and has not had any illness, injury or operation that may affect his/her/their ability to participate in these activities. I (we) will not allow him/her to participate in any class if he/she/they is ill or otherwise injured. I (we) hereby waive any claim against Therapy West, Inc., it's owners or personnel for any and all causes which may arise in connection with participate in this activity.
To Whom It May Concern:The undersigned, parent/legal guardian of First Name* Last Name* , a minor, hereby authorizes Therapy West, Inc., it's owners or personnel to consent to any X-ray, examination, anesthetic, medical or surgical treatment and hospital care to be rendered to said minor under the general or special supervision and upon the advise of a physician and/or surgeon licensed under the provisions of the Medical Practice Act, or to consent to an X-ray, examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to said minor by a dentist licensed under the provision of the Dental Practice Act.It is understood that this authorization is given in advance of any required diagnosis, treatment or hospital care and provides authority and power to the aforementioned agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which a licensed physician or dentist may deem necessary. I (we) further understand that all costs of paramedic transportation, hospitalizations, and any examination, X-ray, or treatment provided in relation to this authorization shall be the responsibility of and shall be borne by the undersigned.This authorization shall remain in effect for one year from the date as indicated below.